Sunday, October 01, 2006

Help Me If You Can...

[posted by dinah]

So my children have both told me that if your parents get divorced you have to go to therapy for a year. Just an observation, I suppose, but they've both come to that conclusion independently. "Maybe", I commented, "it's more about the parents than the kids." Since they present it as a matter-of-fact observation-- maybe putting the child into therapy lessens the parent's guilt over the divorce, gives them the sense that they are somehow rectifying the wrong, counter-acting the damage. Of course, my kids might just be wrong, or missing information about their classmates' distressing symptoms, or maybe at their school, when your parents get divorced, you go to therapy for a year.

This made me think of the time a friend told me that her neighbor's father had died of suicide. "Don't you think she should have therapy for this?" my friend asked. Now that's a hard one; we psychiatrists mostly avoid making treatment recommendations on people we've never met and there is no right answer here. There might be lots of reasons for friend's neighbor to go into therapy: maybe she's inherited her father's mental illness, maybe she's having symptoms of her own psychiatric disorder, perhaps she's remained unduly distraught over the suicide (I'll swing by the issue here of how much distress over such a thing is Too Much distress), or maybe the aftermath of the event has interfered with her own ability to love or to work or to get the most out of life. At any rate, the presumed patient wasn't seeking care. I was left to mutter "probably."

There are some events that everyone reacts to and individual responses vary. As the psychiatrist in the matter, I've simply left it that if you show up at my door saying you're distressed, that's good enough for me. Sometimes I offer reassurance that a response is normal, but never do I kick a patient out and I don't go knocking on doors in search of those who could benefit from care (---not that that's a bad idea, there's a lot of undiagnosed mental illness out there causing misery & dysfunction, perhaps for another post). People seem to vary in their ability to cope with trauma as well as their openness to asking for & getting help. Therapy helps people cope with trauma, it offers some relief through venting and sharing, and empathy (or sympathy?) and understanding, of course. But it doesn't undo trauma, it doesn't excavate all the scars, and not every person who has muddled through a difficult time needs, wants, or even benefits from psychiatric care. Sometimes a good friend (or a Camel) will do, sometimes throwing oneself into activity helps, and of course, sometimes psychiatric treatment is invaluable.

So I wonder how all those kids feel about their year of therapy.


Dr. A said...

I get this question a lot, too, from acquaintences, friends, and sometimes family. "Should I seek counseling and/or medication?" (for mental illness). It's always hard for me to judge, because I know them, sometimes, only in a social setting - and not behind closed doors in an exam room or therapy session.

All I tell them is that it's almost like anything else in medicine, if the person is agreeable - to therapy and/or medication - then, it may be a good idea. If the person is brought kicking and screaming to the doctor or counselor, then it may not be a good idea for that person.

Dinah said...

Dr. A:
The question of "should I get help" is actually a much easier one. If someone is asking the question (especially of their primary care doc) about themselves they may be seeking permission. It seems to me that it's fine to say "Why don't you have a psychiatric evaluation?" --this is a one-time visit (usually an hour and a half to two hours)in which an interview is done and a diagnosis and treatment recommendations are made.

It's a harder question if you don't know the proposed patient, so maybe you're left to say "Why don't you suggest they go for a one-time evaluation?"

In the absence of a dangerous situation, it's difficult to compel someone into treatment. Once people walk in the door, though, they often realize it just isn't so bad or so threatening and sometimes the most resistant of folks end up appreciating the help.

NeoNurseChic said...
This comment has been removed by the author.
ClinkShrink said...

Great topic! I started writing a comment but it got too long so I'm changing it into a post. I'll do the Car Momma followup some other time.

Sarebear said...

The flip side of this might be, how I've told my ologist a couple times, that I think everybody should have therapy, even just a few sessions, every few years or so or something, because it's really cool!

After the third or fourth time I said this over a course of time, he said that not everyone utilizes therapy as well as I do, and that not everyone opens up the way I have.

I sorta felt like he dashed a bit of cold water on me, cause I was really into how much therapy was helping me. I still am, I guess I wish others could know how awesome therapy is.

Well, it's sucky hard sometimes, but I'll take the bad with the good. Bad as in hard and sobbing and frightening and stuff. But then there's the really good parts . . .and, of course, I usually feel better after the hard sessions (on one occasion I didn't and that was REALLY problematic; I did a series of posts on it that week!).

Anyhoo, therapy is cool. Even if it IS scary.

jw said...

I don't know what to think.

I've seen several studies which seem to show that psych/support/therapy after trauma makes things worse for the average person. After the shootings at Dawson (in Montreal) they brought in grief & trauma counselors; do they do good or harm? There is no firm answer.

I know more than a bit about lone fathers. Most lone fathers are single parents due to mom running off, about 55%. One would think that due to our culture's "mom" focus these kids would do worse than other kids, ie "My MOTHER didn't even want me!"

The truth is, psychologically speaking, they do better. Why? No one knows. (One must couch that with the fact that such kids have higher risk of accidental injury, which may have psych portions to it: Again, no one knows. Plus, as Farrell repeatedly points out, lone fathers do better at making sure the NC-mother stays in the kid's lives and that alone may make the difference ... no one knows.)

Similarly, my own bad experience must be brought into the thing as well as the bad experience of others. Things are not at all "all roses" in therapy. There are bad therapists, good therapists make mistakes and all therapists will be bent due to the cultural politics of the day.

Put it all together and what does it mean?

Frankly, I do not know.

Yet, does it not seem that we too often forget that psychology / psychiatry is a medical procedure and therefore a procedure with risks and unwanted side effects?

Julie, RN said...

When I worked primary care, the doctor or I often asked, "Would you like to speak to a counselor about this? They could really help you sort things out."
Of course, then, there would be the red-tape runaround to get insurance precert and all the other (un)necessary hoops to jump though.
But, yeah. Sometimes even a one-time visit with helpful suggestions on coping strategies is beneficial. Hopefully, it would lead to more in-depth visits to bring out the root of this (or other) issue(s), and everybody wins.

Alison Cummins said...

Not all therapists are competent.

Some will just spend their hour chatting about life the way any stranger at a bus stop might, if they don't see anything else obvious to do. These ones probably won't do any direct harm - except that the kids may think they must be really deeply sick if they don't feel "better" or "changed" or recognise their "problem" in the first place even after a year of pointless chat.

Others will use all kinds of freudian tricks to pathologise the most ordinary things. "I got up and had breakfast this morning." "And why do you think you did that?" "Um, I was hungry?" "Mm, really. Is that what you really think?" Yes, this does happen. And yes, these folks will seriously mess up the kids.

Some kids will assume the rôle of patient because that's the one that's assigned to them. Some therapists will go along with this rôle-play without questioning it. Other therapists will yell at the kids for being manipulative malingerers. Even though it wasn't the kid who put in the requst for therapy. (Yes, this does happen.) Some kids will be resistant to this sort of challenge. Others will feel guilty for being manipulative malingerers. Still others will have the lack of a safe place in the world confirmed for them.

Of course, some therapists will offer a safe place for the young person to figure out how to approach age-appropriate developmental tasks without interference from parents who (correctly) don't trust themselves not to impose their own conflicts and neuroses. But this can't be assumed.

Therapy is a really risky proposition. You don't usually get a competent therapist the first time. Therapists can do a lot of damage before you find someone who can help you in a way you can use. They can increase your sense of self-doubt at a time when you need to be able to trust yourself. So I never recommend it to anyone who isn't desperate. It's just not worth the risk.

(Said as someone who has been desperate enough as an adult to repeatedly seek help through therapy, and who has been harmed more often than she has been helped.)

ClinkShrink said...

And by the way I love the cat pic---I 'm sending this to Harold the Vampire Cat's mom.

jw said...

Alison Cummins said... "Said as someone who has been desperate enough as an adult to repeatedly seek help through therapy, and who has been harmed more often than she has been helped."

Replace the "she" with "he" and you've got my own feelings / experience.

I think this is something therapists too often forget. Some patients are going to have repeat very-bad experiences: This is a part of the thing and is systemic for some people. Others will have very good experiences starting with day one. Most will be in between.

Thus, in talking of "safe" places we must realize that "safe" is not always present. The psych-therapy experience may well be VERY unsafe.
For example, thirteen years ago I spoke at some length with a female psychiatrist who REALLY got that point (she contacted me after reading a piece I had published).

She'd been through a very traumatic female offender sex assault ... (even rarer than female offender / male victim). At any rate, her experience in trying to speak of this with her colleague - therapist was disasterous. It was not only unsafe, it was very harmfull.

I'm not advocating all psychologists / psychiatrists go through a severe and socially unacceptable trauma ... yet one would be a fool to not realize that such experience may be the only way(1) to get Joe & Jane Average-Shrink to see what damage can be done.

(1) Given current education, standards and societal attitudes.

Sarebear said...

That Beatles song is going through my head, thanks to this post title.

Over and over and over and over and over and over and . . .